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R inspection Report Number <br /> Waste Tiregey & Inspection ep 11 <br /> Cal Recycle State of California I 1 - 1- 17 6 3 6 3 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey _ - -- — - - - - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: li 01 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalCC i ,/� If Referral,choose referral type(Fill one) <br /> Identifier: JG,� �cct- _/� /,,�r v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ p Inspected By Inspector <br /> P y, t-re s L` A( W ��i� -�—V�C„ G _ t /� <br /> Physical Address l l�[iy1S O tYC{yyl jQU� <br /> , ��j Inspection Date <br /> Com' v c'V(/-t j ��� ` C.A "" Lo Time In Time Outl l l <br /> Business Rep Title 77 AM AM <br /> - 0 PM V O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ® Active ® Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck , <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type(Fill all that apply) <br /> (a New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> * Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 - (Required for NOV or EXTJ N <br /> 459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Y- E <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - --- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> •Comments Included: ® o- —'�i—� <br /> B si 's Tg iature Plione Number s c r' Sigf1 r Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �rrect: Incorrect: � � EX A P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® ■ <br /> 1 <br />